| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 4.2 | The pharmacy supplies medicines in multi-compartment compliance packs to support people in managing their medicines; however, the compliance packs seen do not contain clear dosage instructions, appropriate cautionary and advisory labels, or a clear audit trail identifying who prepared and checked them. This means the pharmacy cannot demonstrate that compliance packs are assembled and supplied safely. |
we have reviewed and strengthened our process for the preparation and supply of multi-compartment compliance packs (MDS). The relevant SOP has been updated to reflect the new process, and all pharmacy team members involved in preparing and checking compliance packs have been briefed on and will work in accordance with the revised procedure. The new process requires the pharmacy PMR system to generate a patient-specific backing sheet for each compliance pack. This includes the relevant medication details, clear dosage instructions, and appropriate cautionary and advisory information. The backing sheet is securely attached to the inside cover of the blister pack so that the required information remains readily available to the patient or their carer. The revised process also ensures that a clear audit trail is maintained to identify the members of the pharmacy team responsible for preparing and checking each compliance pack before supply. |
05/08/2026 | 22/07/2026 |
| 4.3 | The pharmacy cannot provide assurance that the medicines fridge temperature is being monitored effectively. As a result, it cannot always be certain that medicines requiring cold storage have been kept in the correct conditions and remain suitable for supply. The pharmacy has some arrangements in place to manage higher-risk medicines, but its storage and stock management processes are not always sufficiently robust. This increases the risk of stock discrepancies, makes it more difficult to maintain accurate oversight of higher-risk medicines, and reduces the opportunity to identify and address potential issues at an early stage to help keep pharmacy services safe and effective. In addition, records of expiry date checks are not maintained. This increases the risk that some medicines may be overlooked, including those that are expired or approaching their expiry date. |
The pharmacy's existing Daily/Weekly/Monthly Task Sheet has been reinforced as the central tool for ensuring that these activities are completed consistently and at the required frequency. This includes daily monitoring and recording of medicines fridge temperatures, weekly controlled drug balance checks, and monthly stock expiry-date checks. Completed fridge temperatures will be documented on the designated fridge temperature monitoring record, and expiry-date checks will be recorded to provide a clear audit trail that these checks have been completed. The storage and management of higher-risk medicines has also been reviewed and strengthened. A full controlled drug stock balance check was completed following the inspection. All controlled drug register entries and physical stock balances were reviewed, and the identified discrepancies were investigated and resolved. Zomorph and MST are now stored separately and clearly labelled to reduce the risk of selection errors. Ongoing controls: Controlled drug stock balances will be checked regularly and any discrepancy will be investigated immediately and documented. Staff have been reminded of the correct procedures for the storage, recording and checking of controlled drugs. Any apparatus or equipment used in the preparation or handling of higher-risk medicines will be kept separately where appropriate or thoroughly cleaned between uses to minimise the risk of cross-contamination. |
05/08/2026 | 22/07/2026 |
| 1.7 | Some assembled prescriptions awaiting collection are stored in a way that patient confidential information is visible to members of the public using the pharmacy's services. |
The storage area has now been relocated to a more appropriate position behind an additional pharmacy collection counter. All assembled prescriptions are now stored on designated shelving within storage boxes, and underneath the counter positioned so that patient-identifiable and confidential information is not visible or accessible to members of the public. Patients wishing to collect their medication are required to attend the designated collection counter, which is positioned directly in front of and provides a physical barrier to the prescription storage area. The pharmacy team has been reminded of their responsibilities regarding patient confidentiality and the importance of ensuring that prescriptions and any patient-identifiable information are stored securely and out of public view at all times. |
05/08/2026 | 22/07/2026 |
Pharmacy inspections
Inspection reports and learning from inspections